Appendix A Dietary data collection and editing for Year 9 of the NDNS RP

A.1 Diary methodology

This appendix provides an overview of the methodology of dietary data collection and editing for Year 9 of the NDNS RP. An overview of the methodology for Years 1 to 8 is provided in previous reports. Most aspects of the survey methodology remained consistent across fieldwork years; key changes are discussed in the respective reports.1,2,3

Previous NDNS assessed diet using weighed records of several days duration, 7 days for adults aged 19 to 64 years4 and young people aged 4 to 18 years5 and 4 days for children aged 1.5 to 4.5 years6 and people aged 65 years and over.7 Since weighed records incur considerable burden for participants, the decision was made to change the method to 1 with lower participant burden for the new RP.

Prior to the start of the NDNS RP in 2008, a comparison study was carried out in 2007 to compare 2 potential methods: 4 repeat 24-hour recalls and a 4-day estimated diary8 for 1,067 individuals aged 4 years and over. Half the sample participated in interviewer-administered 24-hour recalls (repeated on 4 non-consecutive days) and half kept a 4-day estimated (unweighed) diary on consecutive days.

The NDNS Project Board considered the findings and decided that the 4-day estimated diary would be the dietary assessment method used in the NDNS RP because:

- response rates for the 2 methods were similar: 47% for the estimated diary and 49% for the 24-hour recall
- there was no evidence in the scientific literature of major differences between the methods
- the diary was considered on balance to be a more flexible and adaptable method to cover the wide population age range in the survey. In particular it was thought to be more suitable for young children who may have more than 1 carer The diary method is widely used in the UK, in large studies such as the MRC National Survey of Health and Development (NSHD) (1946 British Birth Cohort), the EPIC Norfolk study, the UK Women's Cohort Study in Leeds and the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort.

A.2 Method

For the NDNS RP, several versions of the diary were developed for different age groups:

- an A5 diary for adults – also available in A4 size for those with vision or writing difficulties
- an A4 diary for children
- an A5 diary for toddlers to be completed by adults

Each version included example pages appropriate to the age group to show how to complete the diary and how much detail to include. For children aged 11 years or younger, a parent/carer was asked to complete the 4-day diary with help from the child as appropriate. Children aged 12 years and older were asked to complete the diary themselves but details were confirmed with others, where necessary. Participants were asked to record food and drinks consumed both at home and away from home, and were therefore asked to take the diary with them when away from home. For young children, who regularly consume meals away from home, a carer pack is issued which consists of 4 separate recording sheets and an information leaflet. A teacher, childminder or friend’s parent, for example, might then complete parts of the diary for the child.

Interviewers undertook 3 visits with each participant. At the first visit, the interviewer placed the diary. The second was a brief visit to check for compliance, answer questions or deal with problems and review the diary to identify and edit possible omissions and missing detail. In certain circumstances, a telephone call could be made in place of a home visit. The third visit was to collect the diary and again review and edit possible omissions. This final visit took place no later than 3 days after the last diary day.

Participants were asked to keep a record of everything eaten or drunk over four consecutive days. If a household contained 2 participants, both participants were assigned the same diary days. When placing the diary, interviewers followed a protocol to explain the method, taking participants through the different sections including the instruction page, how to describe details of food and drink and portion sizes and an example day. The adult diary provided photographs of 10 frequently consumed foods as small, medium and large portion sizes which participants could use for identical or similar foods. Otherwise they were asked to record portion sizes in household measures (e.g. 1 tablespoon of baked beans, 1 Kit Kat (2 fingers)), or for packaged foods to note the weight indicated on the packet. The child and toddler diaries did not include photographs of foods so all portion sizes were recorded in household measures or weights from packaging.

To improve the accuracy of the estimation of portion sizes for children, use of a food photograph atlas designed specifically for young people was piloted in Quarter 2 of Year 3. From Year 4, the atlas was introduced fully into the NDNS RP. Ten different foods were included with the majority of foods displayed as 7 ‘as served’ portions and 7 ‘leftover’ portions (table A.1). Most photographs could be used to estimate amounts for other foods in addition to the actual foods shown e.g. rice could also be used for couscous. These alternatives were listed on a separate card - the Equivalent Foods List (EFL). Participants were instructed to record portion sizes in household measures as usual. For those aged under 16 years, the interviewer used an age-appropriate atlas when reviewing the diary, asking the participant or their parent to select a photo for each food that appeared in the atlas or on the EFL. The photo reference number was then written in the diary alongside the original household measure. Interviewers did not query the photo chosen even if it appeared to conflict with the household measure but they could comment in an evaluation form if they had any concerns.

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4 Newcastle University carried out extensive work developing food atlases containing age-appropriate photographs to be used as a tool for estimating portion sizes in children. In 2007, the Food Standards Agency commissioned work for testing the photographs in a real life setting. Three atlases for three different age groups were developed and validated in 313 children aged 1.5-16 years from the Newcastle area. The children (or their parents for young children) were asked to keep a 4-day weighed diary. An interview took place on the day after the final day of diary recording (day 5) when both the child and parent/carer were asked to estimate portion size served and leftover for each food item using the food photographs in the atlas. The atlas performed well at the group level, producing mean estimates of both portion size for individual foods and mean daily nutrient intakes very close to the values reported in the food diaries. Looking at the accuracy of portion size estimates using the atlas photographs on day 1 compared with day 4, there was no significant difference, i.e. the 4-day gap between day 1 of recording and the interview had no impact on accuracy of estimates. Foster, E., Matthews, J. N. S., Lloyd, J., Marshall, L., Mathers, J. C.M., Nelson, M., Wrieden, W. L., Cornelissen, P., Harris, J. and Adamson, A. J. (2008) The development and evaluation of three portion size assessment tools for use with children. Br J Nutr 99: 175-184.

National Diet and Nutrition Survey Years 1 to 9 of the Rolling Programme (2008/2009 – 2016/2017): Time trend and income analyses Table A.1 List of foods in the food photograph atlas

| Rice krispies | Baked beans | |--------------|-------------| | Cornflakes | Broccoli, boiled | | Rice | Carrots | | Pasta (no sauce) | Peas | | Cheddar cheese | Chips |

In the diaries, leftovers were not recorded separately; participants were asked to take into account leftovers when recording how much they consumed. As a prompt for this, a question at the end of each diary day asked participants whether they had finished all the food and drink they recorded that day. Leftovers tend to be more common with children and a major strength of the food photograph atlas was that each food had a set of leftovers photos. When participants or their parents were asked to select a photo, they were asked to select 1 for the amount ‘served’ and 1 for the amount ‘leftover’.

Participants recorded brand names for foods wherever possible and were asked to collect the food label information/wrappers for any unusual foods and ready meals consumed to help coders identify or clarify items. For homemade dishes, participants were asked to record on a separate page in the diary the individual ingredients and quantities for the whole dish along with a brief description of the cooking method and how much of the dish they had consumed.

In addition to details of what and how much was eaten, participants recorded for each eating occasion; where they were, who they were eating with, whether they were watching TV, and/or sitting at a table. After each day, participants recorded if their intake was typical for that day (and if not, the reason why) and details of any dietary supplements taken. The diary also contained a series of questions about usual eating habits (for example, type of milk or fat spread usually consumed) to facilitate coding in cases where details were omitted in the diet record.

A.3 Dietary data processing

Diaries were returned from the field to be coded by trained coders and editors. Food intakes were entered into a modified version of the Medical Research Council Elsie Widdowson Laboratory (MRC EWL)’s dietary assessment system DINO (Diet In Nutrients Out), an all-in-one dietary recording and

National Diet and Nutrition Survey Years 1 to 9 of the Rolling Programme (2008/2009 – 2016/2017): Time trend and income analyses analysis system written in Microsoft Access. The food composition data used was Public Health England (PHE)’s NDNS Nutrient Databank (NDB), this was incorporated into the DINO system.

Coders attempted to match each food or drink item recorded in the diary with a food code and a portion code from DINO. For composite items which could be split into their component parts, for example sandwiches, each individual component was assigned. If an item had been recorded and there was no suitable code in DINO or there was insufficient detail to code the food, the entry was flagged as a query.

Within DINO, each food code is linked to appropriate portion size descriptors, such as a tablespoon for rice or pasta, which are then linked to the correct weight for that descriptor. So if a participant described their food using household measures, coders would be automatically able to select the appropriate portion size descriptor. If the portion size was described as a weight, the weight would be entered directly into DINO in grams.

Weights for manufactured products such as ready meals, confectionery, crisps etc. were taken from manufacturer or retailer websites. A similar approach was used for items from fast food and similar outlets. The FSA Food Portion Sizes book provided weights for unprocessed foods such as fruit and vegetables and a reference for manufactured items when no other data was available. It also provided weights for small, medium and large portions of typical dishes for adults. For children, age-appropriate portions were used based on the analysis of portion sizes consumed in previous NDNS which were collected using weighed records. For foods consumed at primary and secondary school, portion sizes were taken from data collected from school meal surveys. If necessary, a food would be purchased and weighed. If portion sizes were missing, the entry was flagged as a query.

For children, if a photo reference atlas number had been recorded in the diary alongside the household measure, the coder looked up the corresponding weight in grams of the food in the photograph and also entered this weight into DINO. If a food item had both an atlas and non-atlas (i.e. from a household measure) weight, then it was the atlas weight that was used to calculate food consumption and nutrient intake data. Coders checked all atlas

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b The first 4 years of the NDNS RP were commissioned by the UK Food Standards Agency (FSA) in 2006 with a contribution to funding from the Department of Health (DH) in England. Responsibility for nutrition policy in England transferred from FSA to DH on 1 October 2010. Management of the NDNS RP contract, including management of the NDNS Nutrient Databank (NDB), also transferred to DH at this time. From 1 April 2013, responsibility for the NDNS RP, including ownership of the NDB, transferred to the Department’s Executive Agency, Public Health England (PHE). The survey is now jointly funded by PHE and FSA.

National Diet and Nutrition Survey Years 1 to 9 of the Rolling Programme (2008/2009 – 2016/2017): Time trend and income analyses entries in the diary to ensure that an age-appropriate atlas had been used and that a suitable photograph had been selected.

Where the coder could not resolve the food or portion consumed, the entry was flagged as a query for action by an editor who had greater nutrition knowledge and experience. The editors assigned appropriate codes for all flagged food and portion codes and checked any other queries raised by the coders. In general, where details for the coding of foods were missing, formally agreed default codes were used, such as for the type of milk in tea or coffee in a café, or lasagne eaten at a restaurant. Where portion sizes were missing, an estimate was made using the same weight if the food was consumed on another dietary day, or a portion size consistent with the participant’s usual consumption (e.g. small, medium or large), or an age-appropriate average portion.

For new products not in DINO, editors visited supermarkets or contacted the manufacturer to obtain information on nutrient content in order to decide whether a new food code was needed. This decision was based on nutritional composition compared to that of existing codes, as well as the frequency of consumption, and was made in conjunction with PHE. If a new food code was required, the nutrient content was entered into the NDB. If a portion was used but there was no corresponding portion code on DINO, a new portion code was created using either a weight from an equivalent food, or the food item was weighed and the weight entered into DINO for future use. In the case of school meals, school caterers were contacted for information about the nutrient content and portion size of dishes.

Where a participant consumed a homemade recipe, each individual food item was linked with the food group of the recipe. DINO has the capability to report on these foods both at the recipe level and food level, providing a clearer picture of consumption of components like meat, fish, fruit and vegetables. At the start of the NDNS RP this approach meant that it was possible to reduce the number of foods in the NDB by more than 4,000, to contain over 5,000 food codes, as there was no longer a need to hold numerous variations of the same dish. Having fewer food codes has improved coding efficiency and consistency.

For homemade dishes where a recipe had been recorded, the ingredients were entered individually using the appropriate cooked food codes, and all the codes for the dish were allocated to a recipe food group according to the type of dish. The weight of each cooked ingredient was calculated using the raw weights recorded by the participant, a weight change factor for the whole dish (from a comparable recipe in McCance and Widdowson’s The Composition of Foods series) and the weight of the portion consumed. Where the food was stated as homemade but there was no recipe given, a standard homemade recipe food code was chosen.

A.4 Quality control

At the start of the coding process, editors checked 10 complete diaries for each coder and gave them individual feedback on their work. Additional training and feedback was provided if required. During the coding process, editors undertook a further 100% check of all food and portion code entries of one diary per coder for each fieldwork month. Portion code errors (selecting the wrong portion size descriptor in DINO or entering an incorrect weight) were more common than selecting the wrong food code. Where errors were found they were corrected. These checks ensured that error rates were monitored for all the coders working on the project and helped identify any coding issues. All of the entries flagged as a query by the coders were categorised into 8 query types, such as food code or portion code not available in DINO, recipes, missing or insufficient detail to code food or portion (shown in table A.2).

| Type of diet diary coding query | % of all queries | |---------------------------------------------------------------------|------------------| | Food code not available in DINO | 69 | | Portion code not available in DINO | 12 | | Missing/insufficient detail to code portion | 11 | | Missing/insufficient detail to code food: eaten away from home/... | 4 | | Missing/insufficient detail to code food: NOT eaten away from home/... | 5 | | Other: including queries related to non-nutrition fields such as place, who with etc. | 0(^b) | | Recipe - Missing ingredients/insufficient detail to code food | 1 | | Recipe - Missing amounts | 0 |

(^a) Percentages do not add up to 100 due to rounding (^b) Less than 0.5%

At the end of coding and editing a series of data checking procedures were performed. Initial checks were carried out to highlight any missing data fields, such as incomplete eating context or nutrient variables, followed by a feasibility check of the maximum and minimum portion sizes entered within National Diet and Nutrition Survey Years 1 to 9 of the Rolling Programme (2008/2009 – 2016/2017): Time trend and income analyses each subsidiary food group. Final quality checking was performed using each participant’s mean energy and nutrient intake (all reported nutrients) over the diary period. Extreme intakes were considered as 3 SD from the mean and all entries in this region were checked against the diary. All errors found were corrected to their appropriate entry as reflected by the diary entry. Intakes as a percentage of the dietary reference value for each nutrient were also calculated. For selected nutrients, if a participant’s intake fell outside the 2.5 and 97.5 percentile ranges for their age/sex group, as based on previous NDNS data, they were flagged and checked against the diaries. If results outside the reference range were due to data entry errors then these were also corrected. Those values that were identified as outside the 2.5 - 97.5 percentile range during the data checking process but were not found to be due to data entry errors, were left in the dataset as they reflect actual consumption by participants.

A.4.1 Modifications to the NDNS Nutrient Databank (NDB)

Intakes of nutrients were calculated from the food consumption records using a specially adapted NDB, which was originally developed by the Ministry of Agriculture, Fisheries and Food (MAFF) for the Dietary and Nutritional Survey of British Adults and subsequently updated for the NDNS surveys of children aged 1.5 to 4.5 years, people aged 65 years and over, and young people aged four to 18 years. Ownership of the NDB transferred to the FSA where it was updated for the NDNS of adults aged 19 to 64 years, the Low Income Diet and Nutrition Survey (LIDNS) and prior to commencing the NDNS RP. For Year 9 of the NDNS RP the NDB has been maintained by PHE and MRC EWL.

Each food on the NDB has values assigned for 54 nutrients and energy. The nutrient values assigned to the food codes are based on data from PHE’s programme of nutrient analysis of foods as well as nutritional information provided on food labels. All data were carefully evaluated before being incorporated into the NDB. In order to calculate nutrient intakes from food consumption data it is important that there are no missing values in the databank. Where reliable information was not available for some nutrients, values for such foods were obtained by extrapolating from data for similar foods. For homemade dishes and manufactured products, nutrients were calculated from their constituents using a computer recipe program that allows adjustments to be made for weight and vitamin losses on cooking.

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Nutrients for which range checks were run: total energy, fat, saturated fat and NMES (all as a percentage of total energy) and fibre, thiamin, vitamin C, folate, iron, calcium, zinc and copper.

National Diet and Nutrition Survey Years 1 to 9 of the Rolling Programme (2008/2009 – 2016/2017): Time trend and income analyses In the NDNS RP, it is essential that the NDB is up-to-date and, as far as possible, reflects the nutrient composition of the food supply for each year reported. Each year a programme of updates and revisions are made to the NDB, which are carried out by PHE\\textsuperscript{16} and MRC EWL, so that the databank is up-to-date and, as far as possible, reflects the nutrient composition of the food supply for each survey year reported. Updating of the NDB includes the addition of new foods as well as revision of nutrient composition of existing foods, either at food group level following a programme of reanalysis, or to take account of reformulation by manufacturers and changes in fortification practices. Therefore the same foods may have a different composition for some nutrients in one year of the RP compared to the next. Table A.3 summarises the updates to the NDB that have taken place for Year 9. Currently, the NDB contains over 5,500 foods and drinks, including manufactured products, homemade recipe dishes and dietary supplements.

Table A.3 Updates to the NDB in NDNS RP Year 9

| Reviews of manufacturers’/label data | |--------------------------------------| | Breakfast cereals | | Yogurts, fromage frais and other dairy desserts | | Ice Cream | | Puddings | | Soft drinks | | Sugar preserves and sweet spreads | | Pizza | | Potato products | | Eggs and egg dishes |

Following the definition and recommendations for sugars and fibre being revised in the SACN Carbohydrates report\\textsuperscript{Error! Bookmark not defined.} published in 2015 data for 2 new nutrient variables; free sugars and AOAC fibre were introduced into the NDB for Year 8 and retrospectively for all survey years dating back to Year 1, replacing NMES and NSP. Details of the methodology for determining free sugars and AOAC fibre values in the NDNS RP are provided in appendix AA of this report.

A.4.2 Disaggregation of composite dishes

At the beginning of the RP the NDB contained many composite food codes, which comprised 2 or more ingredient components and related either to purchased or homemade dishes. For some food groups it is important to quantify those foods eaten as part of composite dishes, as well as their discrete portions, to provide more accurate estimates of total amounts consumed at an individual food level. For example, carrots may be eaten as an accompaniment to a main meal, but they may also be consumed as an ingredient within a stew, together with additional vegetables such as onions and celery. In order to determine the total intakes of fruit and vegetables, meats, and fish, a project was undertaken during Year 1 of the RP to retrospectively disaggregate all pre-existing food codes in the NDB. A number of categories for these food types were determined and all foods containing any of these food types (n=3,030) were systematically disaggregated into their components. Following this initial project new food codes are disaggregated prospectively as they are added to the NDB.

The proportion of the composite dish which comprised fruit, vegetable, meat or fish subgroups was determined using a number of sources of information, such as:

- manufactured product information
- standard recipes from McCance and Widdowson’s “The Composition of Foods” series
- homemade recipes from participants’ food diaries
- haem iron data to estimate meat content when other recipe details were not available
- vitamin A content to estimate tomato puree content in condiments and sauces
- fructose content to calculate proportions of fresh and dried fruit in some food codes
- dishes containing dried vegetables, such as dehydrated soups, were scaled up in relation to water content

Disaggregated data allows the estimation of total intakes of fruit, vegetables, meat and fish in the NDNS RP, including the contribution from composite dishes.

A.4.3 Calculation of 5 A Day using disaggregated data

One of the estimates required for reporting is the intake of fruit and vegetables, specifically how participants compare to the recommendations to eat 5 A Day. The information on the fruit and vegetable content of each disaggregated food code was used to calculate the number of portions of fruit and vegetables consumed for each participant aged 11 years and over, using a portion weight of 80 grams (150 grams for fruit juice). In line with the 5 A Day criteria, fruit juice and smoothies combined and pulses (including baked beans) were included in the calculation up to a maximum of 1 portion per day each. The calculations included the fruit and vegetable content of

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[d] The calculation for smoothies changed for Year 9 due to a change in advice in 2016.

**National Diet and Nutrition Survey** Years 1 to 9 of the Rolling Programme (2008/2009 – 2016/2017): Time trend and income analyses foods such as meat, fish, pasta, rice and egg dishes, pizza, breakfast cereals, yogurts and dairy desserts and soups. Puddings and fruit pies were also included as these can contain significant amounts of fruit. However, it was decided to exclude other foods that fell into the ‘high fat/ high sugars’ segment of the Eatwell Guide from the 5 A Day calculations on the grounds that healthy eating advice is to reduce consumption of foods in this group, so it would not be appropriate to include their fruit and vegetable content in the 5 A Day estimates. Therefore the fruit and vegetable content of the following food groups was excluded from the estimates:

- soft drinks (57A, B and C, 58A, B, and C)
- confectionery (43R and 44R)
- cakes (including fruit cake) and biscuits (7A, 7B, 8D and 8E)
- sugar, preserves (including jam) and sweet spreads (41A, 41B, 41R)
- savoury snacks (42R)
- ice cream (53R)

The calculation of 5 A Day portions was performed as follows:

- daily consumption of fruit juice (from 100% fruit juice) and smoothies was limited to 150g – 1 portion
- daily consumption of baked beans and other pulses was limited to 80g – 1 portion
- daily consumption of dried fruit was multiplied by 3 to account for effects of drying
- daily consumption of tomato puree was multiplied by 5 to account for effects of concentration
- total weight of fruit and vegetables (including the weights of baked beans and other pulses, dried fruit and tomato puree, modified as above) was divided by 80 to arrive at the number of fruit and vegetable portions
- fruit juice (from 100% fruit juice) and smoothies were divided by 150 to arrive at the number of portions of fruit juice/smoothies
- the number of fruit and vegetable portions and the number of portions of fruit juice/smoothies were added to give total 5 A Day portions

5 A Day portions were not calculated for children aged 10 years and younger. The 80g portion weight used in the calculation for adults and children aged 11

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(^d) Dried fruit is multiplied by 3 to ensure that it is comparable to non-dried fruit on the basis of their respective micronutrient contents.

(^f) Tomato puree is multiplied by 5 to ensure that it is comparable to canned tomatoes on the basis of their respective carotene contents. For example, 10g tomato puree and 50g canned tomatoes would provide approximately the same amount of carotenes (178.4μg and 181μg respectively).

(^g) The calculation for smoothies changed for Year 9 due to a change in advice in 2016.

**National Diet and Nutrition Survey**

Years 1 to 9 of the Rolling Programme (2008/2009 – 2016/2017): Time trend and income analyses years and over is likely to be too large for younger children but there are few data on which to base the choice of a lower portion weight for this age group.

A.5 Dietary feedback to participants

Participants who completed 3 or 4 diary recording days were asked whether they would like to be sent feedback on the analysis of their diary and how this compared with dietary recommendations. The feedback consisted of the participant’s average daily energy intake and graphs of intake for 8 different nutrients (total fat; saturated fat; non-milk extrinsic sugars (NMES); dietary fibre (as non-starch polysaccharide (NSP)); vitamin C; folate; calcium; and iron), each of which showed the average daily intake, based on the participant’s diet over the diary recording period. The graphs also highlighted the UK guideline intake for the nutrient and the range of observed intakes for the participant’s age group from previous NDNS results so that participants could compare their intake with other people of the same age and sex. The feedback also included general information on sources of healthy eating advice.

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5 SACN Carbohydrates and Health report published in 2015 recommended that the definition for “free sugars” be adopted in the UK and the population average intake of free sugars should not exceed 5% of total dietary energy for those aged 2 years and over. However, dietary feedback has reported NMES intake to participants for Year 9.

6 SACN Carbohydrates and Health report published in 2015 included recommendations for fibre intake for those aged 2 years and over. The DRV for the average adult population intake of fibre is 30g per day defined using the AOAC method of analysis which equates to 23.1g per day NSP, an increase from the previous 18g per day recommendation. However, dietary feedback has reported NSP intake to participants for Year 9.

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McCance and Widdowson’s The Composition of Foods integrated dataset. [Internet]. Available from: www.gov.uk/government/publications/composition-of-foods-integrated-dataset-cofid.

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National Diet and Nutrition Survey Years 1 to 9 of the Rolling Programme (2008/2009 – 2016/2017): Time trend and income analyses www.nhs.uk/Livewell/5ADAY/Pages/5ADAYhome.aspx. 23 [Internet]. Available from: www.gov.uk/government/publications/the-eatwell-guide. 24. SACN Carbohydrates and Health report published in 2015. [Internet]. Available from: www.gov.uk/government/publications/sacn-carbohydrates-and-health-report.